Size Acceptance: Should We Change How We Approach Obesity?

Occasionally my blog deviates from humor and I write about medicine instead. Today I’d like to dip into the public health well. It won’t be funny, but it will hopefully be enlightening.

Image credit: Microsoft Clip Art

Shifting Paradigms

Many of you know I have a professional interest in obesity. It’s no secret the issue is a worldwide problem, and it’s no secret weight loss is the best goal.

Or is it?

A session at the American Public Health Association’s national meeting in New Orleans last month forced me to think about the topic in a whole new paradigm. Or at least try to. We all view the world in a systematic fashion. Anything that challenges our established way of thinking chafes like a wet swimsuit. But closed minds get us nowhere. One look at the world shows us that. So for a few hours, I tried to open mine.

The HAES® model “endorses size acceptance and health practices pursued for well-being rather than weight loss.” They believe putting the emphasis on numbers and scales only leads to stigmatization and fat-shaming.

Reactions like this lead to stigmatization. Weight loss is not the answer to every health problem. (Image by Stephen Taaffe. Shown in one of the HAES® session slides.)

Therefore, when tackling obesity and its numerous complications, our goal should be acceptance not weight loss.

But that seems counterintuitive, doesn’t it? High BMIs* put people at risk for diabetes, hypertension, stroke, heart disease, sleep apnea, and a host of other medical problems. Weight loss improves many of these issues. So while I abhor stigmatization—in fact, my latest novel explores the issues of bullying and fat-shaming, neither of which help my protagonist get healthy—isn’t weight loss the best way to treat these complications? Shouldn’t weight loss be our goal?

That’s always been the paradigm that guided my readings, research, and clinical practice. It’s also the paradigm that guides most clinicians, researchers, and public health professionals.

Which is exactly what ASDAH is trying to change.

Here is what I learned from their fascinating sessions:

1. Before we can shed the stigma of obesity, we need to remove the goal of weight loss. Only when people feel accepted can they truly alter their behaviors.

2. In a study of obese women, those whose treatment was guided by HAES® principles instead of conventional weight loss measures maintained improved eating behaviors better than the control group (for whom restraint and weight loss were the goals). In other words, the control group’s excessive dietary restraint resulted in a return to binge eating. They simply couldn’t maintain the deprivation.

3. Research has shown stigmatization leads to chronic stress and high cortisol levels, which in turn leads to chronic medical problemssuch as heart disease and high blood pressure. So it’s kind of like the chicken and the egg. Does obesity alone lead to chronic health problems or does the stress incurred from societal stigmatization contribute to them, too?

So what now?

Of course, the best way to manage obesity is to prevent it in the first place. This requires multi-level interventions, not just individual behavior changes. But for the two-thirds of American adults and the one-third of American children who are already overweight or obese, weight loss has always been the goal, and in my mind, it still is. After all, we can’t change our established paradigms in one sitting.

But that doesn’t mean I’m closed to new ways of thinking, and I agree, we absolutely must end stigmatization and fat-shaming. But should we also stop pursuing weight loss as the best way for millions of people to get healthy?

Hmm, I’ll need some time to chew on it.

Image credit: Microsoft Clip Art

*BMI is not the best indicator of overweight/obesity, but it’s often the easiest measured and the most often studied for research purposes. But that’s a whole other blog topic…

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Carrie Rubin is a physician and the author of The Seneca Scourge, a medical thriller. For full bio, click here.

263 Responses to “Size Acceptance: Should We Change How We Approach Obesity?”

Glad I’m not the only one late here, and right on time, as we’re dealing with weight-loss when it comes to Younger Son. (He’s a big-boned, big-dude who plays football. He’s a defensive lineman. ‘Nuff said, right?)

I’m always dealing with or feeling a weight issue. Interestingly enough, it was about 6 years ago during the Australian Open Tennis Championships that I started exercising in front of the TV for something to watch, and to take my
mind off the exercise.

IDK what happened with that little start, but I know I had let go the weight-loss outcome. It was then that, one meal or one food at a time, I started to lose weight. I’ve kept pretty much all of it off (except for the 2-5-lb scutch-pounds that yo-yo) off for over 5 years now. Never did I manage longer than 18 months.

Great post. Interesting concept–one that makes a whole lot of sense. I’d get so frustrated when I shopped for clothes, and hate myself for the weight. Then I’d eat at the mall. Food I could buy, and I figured there would be more of me to hate. Nasty, nasty cycle.

Carrie, I came to this post very late – I must have missed it, I don’t know how. But I’m sure you would expect me to have an opinion or two on the obesity issue, and I do.

One aspect of chronic obesity is the very existence of the term itself. The ruthless professionalism of the physical image lobbies and their use of the media have raised it until now it is borderline illegal to have a waistline larger than thirty-six inches. We are constantly exposed to refreshed crusades regarding weight loss which, given that a principle symptom of obesity is low self-esteem, helps not one jot.

In my time I have used almost every diet known to man, apart from a few which were patently absurd. I have lost two, three, even four stone on different occasions, with the one common result. Overwhelming hunger and severe energy loss leading to a net weight gain at the close of each effort.

I am certain my weight problem is down to straightforward chronic addiction. I use the term chronic because I have given up many other things for protracted periods in my life, smoking (as above), drugs, alcohol, etc.. I have never been able to shake over-eating. Sugars and commercial additives are the undoubted culprits.

Interesting then that after ‘investment’ in a bread-maker, which allowed us to control how much sugar went into our bread, my bread consumption reduced by something in the order of two hundred percent. I lost two stone in direct consequence. By dietary change which cuts out nearly all sugar I have been able to alter my eating habits completely. If I never have chocolate, I don’t want it. If I have one piece, I’m hooked. Commercial products, I am convinced, which work OK for some people, have ‘tasters’ in their ingredients which work overtime on me. By cutting out everything, from fish fingers to ready meals, I can lose weight and keep it off. But I have to move through the world in a certain way to do it, while the fitness Nazis – who, let’s face it, are not the most intelligent or the most subtle in the world – hurl insults at me. Sorry, I’ve outstayed my welcome! But I just thought…

Wonderful response. I agree completely, including the part about addiction. The food industry spends millions of dollars to find the right combination of fat, sugar, and salt to keep us eating (something I mention in my book). The food triggers our bliss points and we keep stuffing our mouths. So while they don’t shoulder all the blame, they deserve some of it.

Very impressive that you’ve been able to cut sugar out. That’s tough to do and something I haven’t yet accomplished. Good luck to you and thank you for the thoughtful comment.

Such a terrific post, Carrie, and one that is near and dear to me. The weight battle our nation is fighting seems to be a mercurial subject depending upon what side of the fence you reside: consumer or manufacturer.
Having recently seen the movie FED UP, and preparing for the upcoming publishing of a middle grade novel I have that focuses on “diabesities,” I am always hungry to gather new opinions.
Reading through the comment section, it’s clear this issue is one that still needs desperate attention. I find it inconceivable that our country continues to ignore or dismiss the health data collected on what is sickening our children in order to boost the bottom line of big food business. We’ve created a country filled with dire statistics, and breaking away from the addictions of high fat/salt/sugar foods is becoming an increasingly improbable goal for many folks.
I truly appreciate hearing what you have to say, and I’ve enjoyed reading the words of others as well. I also hope we can cobble together stronger voices within legislation and those that can speak on behalf of the children who are being set up to fail.
Cheers

Wonderful comment. I recently saw the documentary, Fed Up, too, and I’ve read a lot about the food industry. Although I don’t blame them alone, I think they hold a good share of responsibility for the obesity epidemic. They spend millions of dollars to find the right combination of fat, sugar, and salt to keep us eating. I explore this in the novel I’m currently shopping around now. It’s a big interest area of mine. Thanks so much for sharing your thoughts, and good luck with your upcoming novel. Sounds like a great topic.

I first read of this fat-shaming concept in the WSJ, I think, and was so surprised, really. I had thought the exact opposite was the case, i.e. physicians were reluctant to utter the “f” word for fear of losing patients. It’s such a complicated issue and I admit that it’s hard for me to push my own prejudices aside in thinking about it. There’s overweight and then there’s obese, right? And I have to believe there is something going on with those people who don’t stop at 50, 60, 100 pounds overweight that has nothing to do with food except they are using it as a form of medication. Carrie, I strive to consider all points of view and to have an open mind, but it’s hard for me to accept the fundamental premise that we are “Healthy at Every Size.” Excellent, thought-provoking post. Thank you!

Thank you for reading. I do think physicians used to be hesitant to bring it up before and I suspect some still are. But hopefully most are recognizing the issue now and treating it as they would any condition or disorder.

A close relative of mine recently underwent major surgery in which she had half her color removed due to many near cancerous growths. A change in her diet was recommended by her surgeon because her diet was at the heart of her obesity, too. Surgery behind her, her eating habits haven’t changed. On each counter or table she keeps open bags of snacks strategically placed for her to reach into as she walks by, eating continuously throughout the day. I am continually amazed and shocked that the threat of death isn’t enough to change some people’s ways.
Thank you for all of your informative posts.

Behavior change is a complex and difficult thing to achieve. In fact, in public health and medicine, there are several theories of behavior change used to try to develop programs and interventions that might get people to change their behaviors. But as your relative’s case demonstrates, it’s a very difficult task.

Carrie … Years ago, I lost 20 pounds. I could lose a few more, but the drop in weight had positive health results. I was no longer winded when climbing stairs. My blood pressure was lower. Gout – with the aid of allopurinol – was no longer a factor in my life. My husband, who lost about 50 pounds, had similar results (but he never had gout). We try to maintain a health diet, mostly Mediterranean, with a few slip ups for dessert.

If people lose weight for the rights reasons: to be healthier rather than to squeeze into a size zero, than hurrah for them.

A friend, and former co-worker, had surgery to help shrink her size. While she lost weight, she still had a real lack of self-confidence. It’s a shame that she never realized what a wonderful person she was before she committed suicide a few years ago.

So sorry to hear about your friend. How sad. Even when people lose weight, there are often still underlying emotional issues.

I love hearing stories of people who’ve lost weight and as a result got off meds (like blood pressure pills, diabetes drugs, etc.) Goes to show what the power of weight loss can do when health is at stake.

I realized I misstated something. My blood pressure has always been low so the diet didn’t change that. My husband’s blood pressure dropped as a result of his diet. My triglycerides and bad cholesterol dropped as a result of losing weight.

Yes. It was a good thing we decided to change our evil ways (or at least moderate them). 😉

Great post, Carrie. Our current approach clearly isn’t working and I don’t know what makes sense for a workable solution. I think it’s possible we’ve passed the point of no return because childhood obesity is now almost as prevalent as in adulthood. There are so many root causes from pervasive air conditioning and parental fear of children left outside unattended to our present eating habits.

I do think taking the focus off of losing weight is a key component, and yet even in my own family I see a real disconnect between how lousy my overweight relatives feel and what they choose to swallow. If people don’t love themselves enough to care how they feel, they aren’t going to deny themselves the so-called tasty treats.

It’s a viscous cycle. Feel lousy so you eat then you feel lousy from the food you ate, all the while packing on the pounds.

I agree–it’s a vicious cycle because it’s so hard to break the unhealthy pattern. Food is often the only thing that gives a temporary reprieve, the only thing that soothes the troubles. Add to that the addictive quality of sugar and we have a real battle.

Plus I think with some women, heavy weight is an unattractive feature that helps them avoid sex with mates or potential attention from males. I’ve seen that play out with a good friend who was sexually abused as a child as well as a couple of tired Moms who aren’t interested in sex with spouses. All very sad and complicated issues.

I once got reported to the hospital board by a patient with a BMI of 42 for discrimination because I wouldn’t perform her breast reconstruction surgery until she had lost weight. This is a tricky situation as we all know high BMI has high complication rates peri-operatively and also gives very poor aesthetic outcomes with high patient dissatisfaction rate. There is no worse stigmatization than this and yet, I am trying to what is best for her.
I also get obese patients who come to me thinking plastic surgery is a quicker way to weight loss with liposuction and tummy tucks etc. but then get angry at me because I tell them they are not suitable for surgery.
I do love the phrase, ‘I just have to see a salad leaf and I will get fat’. This is typical of a mentality that obesity is not their responsibility nor their own doing. You are definitely right that there has to be a shift in their way of thinking before they can lose weight. Maybe by giving them more self confidence with less stigmatization will empower them to own their problems and do something about it?!
Great post, lots of food for thought!

Thank you. It’s a complex issue, no doubt. It ultimately comes down to the individual, but there are so many other factors that peck at the equation. Only when we tackle it from all angles will we see improvement, and even then sometimes I wonder if we’ll make a dent. I still see the complications of obesity as a reason to maintain weight loss as the goal, but I appreciate how difficult it can be to lose weight when one’s self-confidence and self-esteem is so low. Definitely a vicious cycle.

Agreed. If telling people to lose weight, eat right, and exercise worked, we’d be a nation of fit people. Clearly it’s more complex than that. The sooner we tackle the issue from all sides, the better. Thanks, Kourtney.

I grew up in a society where being fat was encouraged as it showed that one was doing well and living the good life. I have always been naturally slim/skinny and in Zambia I was teased as being “food proof” or rebuked by older people to stop dieting and eat.

I was therefore, surprised when people complimented me on being skinny upon moving to the US. I also started hearing people both on TV and daily life, about how bigger people were too lazy to exercise and gluttonous. Unfortunately, I start thinking the same until I noticed my negativity, scaled it down and started controlling my thoughts. It has not been an easy task, I must say.

Like Kate above said, one way of combating obesity is by teaching children from a very young age about nutritious food, encourage mandatory physical education classes in school and teach them how to cook as well. Adults can also be taught the same things at churches.

Interesting how weight is a cultural issue as well–you getting teased in your native country for being thin and people being fat-shamed here in the US. I suppose that’s all the more reason for self-acceptance–we can’t get our validation from others. We have to be happy with who we are, and when we are, we can hopefully make choices that will lead us to a healthier life. Thank you so much for sharing your perspective. I find it fascinating to hear of such opposing attitudes. And thank you for visiting. Much appreciated!

I’ve battled with keeping a “normal” weight my whole life. In my teens and twenties I was able to do it. In my early thirties I hovered on the line between “normal” and “overweight” on the BMI. Now I think I’m probably on the low end of the “overweight” category. To lose weight, and be healthier, I know what I need to do: eat more veggies, cut out the wine and empty calories, exercise more, etc. The problem is I’m often too lazy, or I really want to eat that piece of cake. How do you motivate the people who know what the need to do, but just don’t want to?

Yes, I’ve been to NOLA! One of my favorite cities (probably for the food and drinks!). The Carousel Bar is one of my faves, also Molly’s at the Market and Coops. Mmmm… I need to plan another trip!

Getting people to change their behaviors is a tricky thing, no doubt. In fact, there are several theories of health behavior and how best to invoke change that can help guide clinicians. But it’s not easy. It has to start with the individual. Unfortunately, an individual’s social structure, community, and environment all go into the equation and can hinder an real change. A complex issue for sure!

New Orleans was wonderful. Wish I would’ve had time to see more, but I was busy with the conference. I enjoyed walking around the French Quarter though. Very cool.

i am inclined to think if we educated kids in elementary and middle school — a real class that is as important as math and language arts, that meets daily and has homework and tests, we would have healthier adults. But, of course, the problem runs deeper than lack of knowledge for many obese people, and we have to help different people in different ways. there is not a one size fits all solution. Great post!

Thank you. I agree, I wish we had a better health curriculum for our kids, starting at a young age. I know they get some nutritional info, but as you allude to, those classes don’t carry the same weight as others and they don’t tend to have lasting effects. And of course, parents don’t always listen when their kids come home from school and tell them about the things they learned about portion sizes and eating well. The kids may want to change things, but it’s the parents who buy and prepare the food.

This topic has always baffled me. I get that we’re not supposed to make fun of obese people and that we shouldn’t make them self-conscious in a humiliating/embarrassing kind of way, but at the same this is not something that should be ignored. If a person is fat to the point of being healthy, they should be made aware of it and given advice regarding the best steps to take to get back on the right track, and by that I mean the path of healthiness; they don’t really need to become stick figures to be healthy.

I think the key here is WHO tells them that – their doctor, a close friend or a parent seem to be the ideal choices here.

I agree the emphasis should be on healthiness rather than specific numbers, and as you point out, if someone’s health is at risk, something needs to be done. I still feel like weight loss is an important goal here, but maybe we need to find more sensitive ways to approach it.